When the President announced a reversal of policy, preventing transgender individuals from serving in the military, a major reason given was the medical cost. But why would individuals of military age still be receiving transition surgery? This question never arose. That silence speaks loudly to our nationwide ignorance of transgender biology, and to the fact that some in our medical community persist in putting off the decision to transition, encouraging patients to wait until they are “more mature.”

In our society, most citizens still do not know the difference between gender and sexuality. They confuse transsexuals with lesbian and gay individuals because it is the last letter in the LGBT acronym. Being born with a gender identity that does not agree with your anatomy has nothing to do with sexuality.

“Sex” was the only term we used before the 1950s. But it did not explain the variations in behavior and anatomy. Not all male homosexuals were effeminate nor were all lesbians masculine.

Dr. John Money at the Psychohormonal Unit at Johns Hopkins University was the person who borrowed the term “gender” from its usage in language and applied it to the masculine-to-feminine spectrum. His unit was a center for helping parents decide what to do with babies who were born with ambiguous genitalia. Johns Hopkins was the center for conducting the transition surgery for some of the first pioneer sports figures who switched between male and female in the 1950s and 1960s.

Money documented cases where children by age five or six expressed a profound and definite conviction that “I am not a boy; I want to be a girl like my sister is...” despite normal male anatomy. Money’s experiences resulted in a pioneer book with colleague Anke Ehrhardt: “Man and Woman, Boy and Girl” where the sequence of development and differentiation was carefully explained.

The presence of genes on the Y-chromosome (usually) causes the development of fetal testes that provide fetal hormones that (usually) drive the development of fetal male anatomy and affect the brain. A young boy (usually) develops a male body image and (usually) responds as a masculine boy in response to other’s behavior. At puberty, the male anatomy (usually) develops along with masculine behavior and normal male eroticism (sexual attraction to females). The absence of a Y-chromosome (usually) results in the cascade of female anatomy, hormones, femininity and female eroticism. These many cases of “usually” reflect the many exceptions that Money saw at his unit for diagnosis and treatment. I used Money’s book in high school biology starting in 1975. Students left class thankful they were normal.

However, when Money was diagnosed with rapid onset Parkinsons, he remained uncertain if the feeling of masculinity or femininity developed in the first years of childhood or in the last trimester of fetal development during pregnancy. That issue soon became settled by brain anatomy research by Dick Swaab and his associates in the Netherlands: gender identity develops before birth.

Dr. Money died in 2006 and I was one of a few invited to his memorial service. Johns Hopkins Hospital was not represented because they had abandoned this work. The new psychiatrist-in-chief at Johns Hopkins Hospital, Paul R. McHugh considered transgenderism to be a “mental disorder” that needed treatment and considered sex change to be “biologically impossible.” McHugh has now retired. And Johns Hopkins Hospital is returning to sex reassignment surgery.

But the practice of delaying puberty through the age of 18 or 21 by using puberty blocker drugs so a child can be “really certain” continues. It ignores the extensive successful surgeries done when there is solid and strong indication of gender by age of five or six. Hormone therapy and surgery conducted after a person has finished growing do not provide as satisfactory an outcome.

Awaiting adulthood to conduct transition hormones and surgery contradicts the biological need to use hormones and surgery as soon as possible. Treated earlier, trans individuals would enter the armed forces as men or women—no more surgery needed.

To understand these youngsters' dilemma, the PBS documentary “Frontline: Growing Up Trans” is available from PBS.

This recent controversy did reveal that our armed forces spend far more on Viagra for the troops than they spend for belated transition surgery. If you had your windows open when that hit the news, you could probably hear 150 million women across America scream: “What!”